Reposted with permission from the Applied Behavioral Science Institution in Michigan

According to the CDC, as many as one in 44 children fall somewhere on the autism spectrum. Receiving a diagnosis of Autism Spectrum Disorder can be frightening and cause uncertainty when it comes to treatment. Fortunately, several time-tested behavioral therapy methods have been used to help children with autism socialize, take perspectives of others, and learn new skills with less frustration. Learn more about discrete trial training, which is a specialized subset of applied behavior analysis, below.

What Is DTT?

Discrete trial training uses several steps to teach a child a new skill. By breaking up a larger or more complicated task into specific, smaller steps, the child can focus on learning one at a time and building up to the full concept. Each step can be considered a “trial” or a teaching attempt. When the child masters one, they may move to the next.

What Are The Five Steps of DTT? 

DTT uses bite-sized steps that allow the child to master smaller skills before moving on to larger ones. Below are the five steps typically involved in a DTT session. 

1. Discriminative Stimulus

This step involves the teacher showing the child the task they will be completing. The teacher may place cards on the table, ask a question about an object in her hand, or say another phrase that will help the child discern what their part in the activity should be.

2. Prompt 

The prompt may be used to help direct the child toward the correct response. For example, a teacher may ask, “where is the blue card?” and place their hand near the blue card on the table to guide a child who has trouble responding.

3. Child Response

The child will answer the question or complete the task assigned in the discriminative stimulus. Remember, these tasks are small and should allow the child to respond with correct or incorrect answers. Responses do not have to be verbal.

4. Consequence

If the child responds with the correct answer, the teacher responds positively. This can include praise, candy, a sticker, or anything else the child sees as desirable. The child can know of the reward ahead of time. If the child responds incorrectly, it’s very important not to “punish” the wrong answer. Simply focus on correcting without negative emotion and move forward to the next trial.

5. Inter-Trial Interval

This interval refers to the short period of time between the consequence and the next trial. It is often extremely short (under five seconds).

Who Can Benefit From DTT?

Children with autism who are around two to six years old often see the most benefit from DTT, but people of any age can learn new skills in a controlled, calm environment with this method. The possibilities are wide-ranging: Children on the autism spectrum can learn social skills, increase their communication with others, and practice habits used in daily living activities such as getting dressed independently, following directions at school, and eating at the dinner table.

About The Applied Behavioral Science Institution

Building a better world through applied behavioral science

Our mission is to provide applied behavior analysis therapeutic interventions in the home environment of West Michigan residents. Applied behavior analysis uses best practice approaches as developed by peer reviewed literature to improve language and social skills, and curb problem behaviors for children with autism. Learn more at https://appliedbehavioralscience.org/

This month’s ASAT feature comes to us from Juliana Oliveira, PhD, BCBA-D, and Alice Shillingsburg, PhD, BCBA-D (University of Nebraska Medical Center – Munroe Meyer Institute). To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!

I am a newly minted BCBA consulting for a team in a public-school setting for an 8-year-old boy with ASD. He has a history of escape-motivated behavior (e.g., refusal to do his homework) which appears to have progressed to engaging in avoidant behaviors as soon as he is approached by several of his providers. I am familiar with the importance of pairing to enhance rapport with a student but am looking for ways to best address this with his team. Do you have any suggestions for framing the need as well as specific strategies?

This is an interesting and timely question, and you are most certainly not the only provider to go through situations related to escaped-motivated behavior. There are a variety of evidence-based procedures that could be helpful in this situation, but you are right that emphasizing rapport between teachers and students is an important element to consider.

Escape-motivated behavior in the classroom?

Some behaviors demonstrated by students occur in order to avoid or escape aversive situations. Through our life history, we learn to identify and predict when unpleasant events are about to occur and act in ways to avoid or escape those impending unpleasant situations. For example, a student may have learned over time that when their teacher gets up from their desk and approaches with a bin of materials or a folder of worksheets, that they are going to be asked to put preferred toys away and begin working on tasks. Initially, the student may begin to engage in behaviors such as running away from their desk and/or shouting, to get out of doing work tasks. Over time, the student may start to engage in those same behaviors, just at the sight of the teacher approaching with materials. In extreme examples, students may sometimes avoid going into their classrooms at all. Of course, this cycle of behavior poses significant barriers to learning and teachers can often find themselves wondering how to teach students who won’t come to the classroom or to their desk, who refuse to engage with educational materials, or who engage in disruptive or dangerous behaviors when presented with learning tasks.

What can we do about it?

Functional communication training (FCT) is a commonly used and effective intervention strategy to teach students to use communication skills rather than engaging in avoidant behaviors in the classroom (e.g., Shawler & Celiberti, 2019). However, another important strategy to resolve situations like the one described above, or to prevent the situation from happening at all, is to prioritize rapport-building strategies in the classroom between the student and the teachers.

Developing a good relationship between the teacher and the student can be viewed as an antecedent intervention, something we do before challenging behaviors arise, that sets the stage for ongoing productive learning in the classroom. For many students, developing a strong relationship will happen easily and quickly. For others, more specific and intentional strategies may be needed, and the process may take longer. In either case, a strong relationship between the teacher and student will come in handy as learning tasks become more difficult over time.

Therapeutic procedures aimed at building a strong relationship have been called pairing or pre-session pairing (Kelly, et al., 2015; Shillingsburg, et al., 2014; Shillingsburg, et al., 2019), rapport-building (McLaughlin & Carr, 2005; Weiss, 2001), and relationship-building interventions (Parsons, et al. 2016). Although these are different terms, they all describe interventions that include pairing the teacher with the presentation of strong, positive reinforcers to the student throughout their interaction. Through this process, the instructor, setting, and materials become associated with, or conditioned as, positive and reinforcing as well. Although the pairing procedure is often highlighted in the beginning of instruction, it is not limited to these sessions. Pairing, or rapport-building, is an ongoing effort of the teacher, to make sure that the teacher-student relationship remains strong, particularly given the intensity and duration of many of these relationships with students with autism.

Based on our previous experiences and observations, it can often happen that a previously good relationship between teacher and student deteriorates over time. Some reports such as “In the last few sessions, the student started to run from me every time he saw me”, or “The student is not cooperating with my instructions as much as he used to” are not unusual. However, escaping or avoiding teachers is not a lost battle. It is possible to rebuild trust and rapport by conducting the pairing procedure again.

What are the specific strategies?

The pairing procedure can sound like a very general concept but is much more strategic and intentional than simply providing reinforcers and refraining from instructions. Here are some guidelines and strategies that teachers – including the entire multi-disciplinary team that provides services to the student – can follow to effectively pair themselves with preferred activities, objects, and events and eventually work toward an effective teaching session with an engaged student.

No demands at first. – When establishing rapport, we try to avoid placing demands on the student or requiring participating in non-preferred activities. This might be difficult to envision in a classroom setting where teaching is what we are supposed to be doing. But rest assured, the pairing process sets the stage for high quality teaching with a student who has chosen to participate and is the soil in which good teaching can take root!! If you can find a way to structure the day to limit non-essential demands in the first days with your student, your long-term interactions will benefit. As discussed earlier, the goal of these first sessions is to pair the instructor, setting, and materials with strong positive reinforcers. This is always the first goal and first step in teaching.

Select preferred items to use. – Be intentional about the items you will use during the pairing sessions. You can use preference assessments, reinforcer inventories, and observations of the student to determine what items could be used as reinforcers – this can include toys, activities, food, drinks, and favorite conversation topics. It is also important to ensure you have numerous preferred items and activities, so you can rotate them throughout the sessions. For example, if the student likes musical toys, having multiple musical toys (e.g., keyboard, drum, cymbals) might be more effective than having only one musical toy. Make note of the student’s responsivity to different items (e.g., item appeared very motivating, interest was sustained over several minutes, seemed powerful one session but not the next).

Setting up. – Sit at the table or on a specific area on the floor with all the student’s preferred items. You will be constantly presenting items to the student, so you want these materials within YOUR arms’ reach so that you can deliver the items as the student shows interest. For example, if the student is playing with a musical toy, but starts to look at a Play-Doh, indicating interest, you can immediately deliver the Play-Doh to the student.

The items that you set up should always be in your possession and under your control. This is because the pairing process entails you, the teacher, as the giver of great things. If the items are within the student’s reach and not in your possession, you become less relevant and won’t necessarily be paired with the preferred items. The key here is that engaging in fun and preferred things happens with you. You can use strategic solutions to make sure that the items are in your control, such as putting the items in plastic bins, on shelves, in plastic bags, in your pocket, etc. At every instance that the student shows interest in a new item or activity, you provide it.

Capture and contrive motivation to engage with the instructor. – At the start of the pairing process, observe what seems to interest your student. If you identify that specific items and activities are preferred by your student, keep giving those things to them. Additionally, throughout the session, it is important to ask yourself the following questions:

• Is there a way for me to have the student continue coming back to me to get more of this item?
• Can I change the activity in such a way that it is more fun with me than without me?
• Can I make myself a critical component of engagement in this activity?

For example, let’s say the provider and the student are playing with a highly preferred puzzle. The student could have all the pieces of the puzzle for himself, and there would be no need to interact with the provider. However, to try to favorably answer the previous three questions, the provider could first present the box of the puzzle to the student. If the student engages in a response indicating interest, such as reaching to the box, looking, or smiling at the box, the provider could open the box and provide a few puzzle pieces for the student (question 3). Then, the provider could keep delivering the pieces “for free” or after indicating responses from the student (questions 1 and 3). For every delivery, the provider could engage in silly sound effects, or could label the piece (“Wow! We found the eye!”), and so on (question 2). Overall, the instructor is actively trying to capture and contrive motivation.

Follow their lead to play and engage. Be a good “reader” of your student. – Play and engage with what your student wants to play with. If their motivation changes throughout the play, you will follow along with what they want to do. For example, the student may lose interest in the current activity and indicate, verbally or nonverbally, for a different activity. When this happens, be quick and attentive to respond to subtle cues of your student’s changing or diminishing interests as missing these cues may lead to problematic behavior. For example, if you are playing with the puzzle and you notice that your student is not engaging in indicating responses to do more of the puzzle, but rather, starts looking around the room for another toy, be responsive to those early indicators. You can offer other activities until signs of interest occur and then follow their lead.

As you introduce items, don’t persist if there is no interest. When presenting a new activity or item, initially you can simply model how to engage with the activity and monitor if interest increases. If that is the case, keep providing more of that item. If you notice that interest is starting to decrease, try other things. For example, if the student is interested in building a block tower, you can 1) provide more blocks to him; 2) give the student some blocks and you can both build a tower together); or 3) build a block tower next to theirs. If the student starts to lose interest in the tower, you can model other structures to build, or you can engage in a different activity.

Use sensory-social play. – For some students, sensory-social play is highly engaging. When engaging with the student, add big movements, exaggerated facial expressions, and a sensory element to songs or play routines (e.g., doing wiggle arms, tickle spiders, ups and downs). During those play routines, make sure to build anticipation: Repeat the same words or sequence of movements over and over in the same manner and then pause (e.g., “I’m going to get . . .you”, “Ready, set . . . go!”, “1, 2, ….3”). Another important tip is to engage on the same level and face-to-face with your student, as this might increase the chances that your face and voice become paired with preferred activities. However, an important note about physical proximity is to know what your student feels comfortable or uncomfortable with. Some learners will enjoy tickles and loud voices, while other learners will prefer quieter interactions. These suggestions should also consider the student’s age and other individualized considerations.

Talk to your student. – Throughout your pairing sessions, pair words/sounds with what the student is doing (e.g., while the student is bouncing on a ball say, “bounce, bounce, bounce.”). Also, pair words/sounds with what the student is attending to (e.g., while the student is looking at the orange tiger on the pop-up toy, say “orange!”). You can also reflect on what they say (e.g., after the student says, “Crash!” as they crash their truck, you say, “Crash!”), and with a minimally verbal student, this can mean just imitating his vocalizations (e.g., while the student is looking at the ball and says “bah”, say “bah! Ball!”).

Listen to your student. – Be the best conversation partner they’ve ever had (i.e., nod, smile, agree, ask follow-up questions about their topic). Questions that sound like demands should be avoided (as discussed in the first strategy – no demands at first).

Plan how to fade in the demands. – After several sessions of pairing, you can start planning to introduce demands. Initially, it is crucial to add demands that the learner already knows how to answer, and that are easy for the student. After a while, you can gradually increase the level of difficulty or the rate of responding during the session. Instructional fading is an evidence-based approach to preventing escape/avoidant behaviors during instructional settings. We generally start with low frequency, low effort instructions, and gradually fade in more (Pace et al., 1993). It is also important to ensure the things we are asking students to do are meaningful and engaging. Curriculum revision, where aversive, non-essential tasks are replaced, is also an evidence-based approach to reducing escape behaviors (Geiger et al., 2010). It is not a great approach to teach students to tolerate poor instruction that involves meaningless objectives. As you fade in more learning opportunities and as these learning opportunities get more difficult, you should monitor engagement, choice to come to the teaching setting, and whether avoidant behaviors are absent. For a more detailed description of how demands can be gradually incorporated during the session, see Shillingsburg et al. (2019).

Putting it all together

Overall, children diagnosed with autism spectrum disorder receive a large amount of intervention hours per week, with different professionals, in different settings. Additionally, instructional sessions for students with autism are often long in duration. Our engagement with students may wane at times, necessitating one or more members of the team to revisit the suggestions above. The instructional sessions have the goal to teach a variety of social and academic acquisition targets, often in a discrete trial teaching arrangement, which can lead to escape-motivated behaviors. The pairing procedure is an antecedent intervention that focuses on building strong therapeutic rapport. As compassionate providers, our hope is that our students genuinely want to participate in therapeutic and instructional settings and want to engage with the different providers. In this way, we might decrease the chances of escape-motivated problem behaviors, while increasing learning and happiness.

References

Geiger, K. B., Carr, J. E., & LeBlanc, L. A. (2010). Function-based treatments for escape-maintained problem behavior: A treatment-selection model for practicing behavior analysts. Behavior Analysis in Practice, 3, 22-32.

Kelly, A. N., Axe, J. B., Allen, R. F., & Maguire, R. W. (2015). Effects of presession pairing on the challenging behavior and academic responding of children with autism. Behavioral Interventions, 30, 135-156.

McLaughlin, D. M., & Carr, E. G. (2005). Quality of rapport as a setting event for problem behavior: Assessment and intervention. Journal of Positive Behavior Interventions, 7, 68-91.

Pace, G. M., Iwata, B. A., Cowdery, G. E., Andree, P. J., & McIntyre, T. (1993). Stimulus (instructional) fading during extinction of self-injurious escape behavior. Journal of Applied Behavior Analysis, 26, 205-212.

Parsons, M. B., Bentley, E., Solari, T., & Reid, D. H. (2016). Familiarizing new staff for working with adults with severe disabilities: A case for relationship building. Behavior Analysis in Practice, 9, 211-222.

Shawler, L., & Celiberti, D. (2019). Clinical corner: What is functional communication training? Science in Autism Treatment, 16(12).

Shillingsburg, M. A., Bowen, C. N., & Shapiro, S. K. (2014). Increasing social approach and decreasing social avoidance in children with autism spectrum disorder during discrete trial training. Research in Autism Spectrum Disorders, 8, 1443-1453.

Shillingsburg, M. A., Hansen, B., & Wright, M. (2019). Rapport building and instructional fading prior to Discrete Trial Instruction: Moving from child-led play to intensive teaching. Behavior Modification, 43(2), 288-306.

Weiss, M. J. (2001). Expanding ABA intervention in intensive programs for children with autism: The inclusion of natural environment training and fluency-based instruction. The Behavior Analyst Today, 2, 182-186.

Citation for this article:

Oliveira, J., & Shillingsburg, A. (2023). Clinical Corner: Building rapport with students using specific strategies to promote pairing. Science in Autism Treatment, 20(12).

About the Authors

Juliana Oliveira, PhD, BCBA-D, is a postdoctoral fellow at the Integrated Center for autism spectrum disorders (iCASD), at the University of Nebraska Medical Center (UNMC) Munroe-Meyer Institute (MMI). She obtained her bachelor’s degree in psychology at the Federal University of Para (UFPA) in Brazil, and her M.S. degree in Experimental Behavior Analysis also at UFPA. Juliana conducted research on conditional discriminations with Cebus apella monkeys,stimulus-stimulus pairing procedures to induce vocalization with children diagnosed with autism, and caregiver training for toddlers and children diagnosed with autism. Later, she moved to Texas and obtained her doctorate at Texas Christian University (TCU). During that time, Juliana worked on a series of studies that evaluated the efficiency and other potential benefits of equivalence-based instruction, while remotely consulting families back in Brazil. In her current position, Juliana is providing ABA services to dyads and small groups of children diagnosed with autism. She is also interested in assessing different teaching procedures to teach verbal behavior and to assess the emergence of different verbal operants. She is addicted to shrimp (any kind of shrimp!) and loves to go to the beach.

Alice Shillingsburg, PhD, BCBA-D, LP is the Yale Family Endowed Professor and Director of the integrated Center for Autism Spectrum Disorders at the University of Nebraska Medical Center’s Munroe-Meyer Institute. She received her PhD in child clinical psychology at Auburn University and completed her APA Accredited doctoral Internship at the Marcus Institute in Atlanta, GA. In prior roles, she has served as Sr. Vice President of Children’s Clinical Services and Training at May Institute, Director of the Language and Learning Clinic at Marcus Autism Center, and held an appointment as Associate Professor at Emory University School of Medicine in the Department of Pediatrics.

Dr. Shillingsburg’s research and clinical interests involve the development and implementation of comprehensive and focused interventions to promote robust, meaningful skill development for children and adolescents diagnosed with autism. Dr. Shillingsburg has published over 60 empirical research articles and book chapters, is current Editor-in-Chief of Operants Magazine, and is past Associate Editor for the Journal of Applied Behavior Analysis and The Analysis of Verbal Behavior.